Monday, November 17, 2014

Case Reports of Synthetic Cannabinoid-Related Deaths

Several case reports of synthetic
cannabinoid-related presentations to the emergency department in clinical
toxicology have been published, but more often than not (for valid and invalid reasons), analytical confirmation of drug in the
blood is not even attempted. In postmortem toxicology, these reports are exceedingly rare as only few case
reports have been published surrounding circumstances of death.

There have been three case report papers published in 2013-2014 describing
synthetic cannabinoid-associated deaths in
conjunction with analytical confirmation of the specific substance and discussion
of any associated pathology or physical findings at autopsy. This combination is what I call the "holy grail" of forensic toxicology. And no, this isn't a Monty Python sketch...

Case history + Analytical Confirmation + Autopsy Findings

It is through
these case reports and those like them that we will begin to understand the
postmortem toxicology of synthetic cannabinoids.

This case was reported out of out of Sweden by the Department of
Forensic Genetics and Forensic Toxicology, National Board of Forensic Medicine,
and the Division of Drug Research, Linkoping University and describes a fatal
intoxication with methoxetamine, AM-694, AM-2201, and JWH-018.

A 26 year old male was found lying deceased on the floor in his
apartment. There were several bags found in the residence. One bag was labeled “2-(3-methoxyphenyl)-2-(ethylamino)-cyclohexanone”, which is the chemical name for methoxetamine,
and another bag was labeled as “Haze”.

It is of interest to me that methoxetamine was determined to
be the substance at play in the cause of death. While not specifically included
in the cause of death ruling, the authors do make note in the paper that it is
possible the synthetic cannabinoids detected may have played a role in
contributing to cause of death. Venlafaxine and metabolite were detected at “therapeutic”
concentrations.

This case was reported out of Sweden by the Department of
Forensic Genetics and Forensic Toxicology, National Board of Forensic Medicine,
and the Division of Drug Research, Linkoping University and describes a fatal intoxication
with JWH-210.

A 17 year old male was found dead outdoors. An herbal
potpourri product named “Smoke XXX” was found in his clothes pocket. Witness
reports describe the smoking of the product. A ‘friend’ took two puffs, felt
dizzy, and lost “his perception of touch” in his hands. The friend decided to
move indoors while the deceased continued to use the product outdoors.

Femoral blood toxicological findings consisted of only JWH-210,
which was at a concentration of 12 ng/g. Pulmonary edema was detected at
autopsy. The total weight of the lungs was 1,264 grams. No other remarkable
findings were observed. Cause of death was determined as hypothermia in
combination with psychotropic substances. Manner of death was accident.

Case 3

Four Postmortem Case Reports with Quantitative Detection of the
Synthetic Cannabinoid, 5F-PB-22

These cases were reported out of the University of Iowa Hospitals and
Clinics; Department of Pathology and Laboratory Medicine, Mercy Medical Center;
Physicians Laboratory, PC; and AIT Laboratories. The case reports describe a series
of fatal intoxications with 5F-PB-22.

Case 3.1

A 17 year old male
was using drugs (including ethanol) with a friend. During the early morning
hours, he “began to gasp for air” and collapsed to the ground. After failed resuscitative
attempts by EMS, he was pronounced dead.

Femoral blood
toxicological findings consisted of 5F-PB-22 (1.1 ng/mL), ethanol (0.033%),
amiodarone, and caffeine. Upon autopsy, no remarkable findings were observed.
Cause of death was determined to be 5F-PB-22 intoxication. Manner of death was
accident.

Case 3.2

A 27 year old male
was brought to the ER with illness and diaphoresis. Upon admission he was
diagnosed with acute liver and kidney injuries. After admission to ICU, he was
diagnosed with “severe liver injury, severe coagulopathy, acute kidney injury,
acute respiratory failure, hypoxemia, severe anion gap metabolic and lactic
acidosis”. The patient’s condition deteriorated rapidly over the next half day
and he experienced cardiac arrest and “pulseless electrical activity and poor
oxygenation secondary to acute respiratory distress syndrome likely the result
of aspiration and pulmonary contusions following chest compressions”. Failure
of the circulatory system, respiratory system and central nervous system
followed along with severe metabolic derangement.

An antemortem serum
specimen obtained approximately 7 hours prior to death was positive for
5F-PB-22 (1.3 ng/mL). The only other drugs detected were THC-COOH and drugs
administred during medical intervention (piperacillin, levofloxacin, and
lorazepam). Cause of death was determined to be fulminant liver failure in the setting
of THC and 5F-PB-22. Manner of death was undetermined.

Case 3.3

After a night of
partying with friends, an 18 year old male decided to go to sleep at 9:45 am.
He was found in bed unresponsive, pulseless, not breathing, and cool to the
touch at 1:42 pm.

Postmortem Iliac
blood toxicological findings consisted of only 5F-PB-22 (1.5 ng/mL). Bilateral
pulmonary vasocongestion and congestion of the liver, spleen, and kidneys was
observed at autopsy. No other remarkable findings were observed. Cause of death
was sudden death in association with synthetic cannabinoid use. Matter of death
was accident.

Case 3.4

After a night of
partying, a 19 year old male returned home and indicated to his family he felt
lightheaded. Around 12 noon, he decided to go to sleep. He was discovered
deceased in his bed the next morning.

Postmortem superior
vena cava blood was positive for 5F-PB-22 (1.5 ng/mL). No other drugs were
detected. Remarkable findings at autopsy included bilateral pulmonary edema,
necrotizing granulomatous inflammation with histoplasma microorganisms, and
visceral congestion. Cause of death was acute drug intoxication with the
synthetic cannabinoid, 5F-PB-22. Manner of death was accident.

It is of great importance to recognize that in the vast
majority of the cases reported, relatively nonspecific pathological findings
were observed at autopsy. These include pulmonary edema and various visceral
congestion. In 83.3% of cases (cases 1, 2, 3.1, 3.3, and 3.4), these were the
only physical findings observed.

I hope to see more of these types of case reports published. In my opinion, it is not enough to just publish a case without analytical confirmation AND without at least some discussion of pathology/findings at autopsy.